Drive for safe management of severely ill patients with anorexia

There was close audience engagement and discussion throughout the latest Master Class focusing on the physical management of severely ill patients with anorexia.

Leading the Master Class which took place on January 23, Dr Paul Robinson spoke of his deep personal commitment for improving the care for acutely ill patients who come into general medical wards.

He described distressing examples of patients who had died after mistakes were made on these wards by clinicians with little or no experience of eating disorders.

“I felt we as a profession needed to do something about it and stop this from happening,” Dr Robinson told the audience, describing his motivation for beginning the process of establishing national guidelines.

“There are units like Newbridge and other great places where we have all worked and as specialists, we need to do all we can to support safe practice in general hospitals, which is often the first place where severely ill people with anorexia are seen.”

The latest Newbridge House Master Class was a focus on the MARSIPAN guidelines (management of really sick patients with anorexia nervosa) delivered by the psychiatrist who initiated the drive to develop the guidelines.

Dr Robinson led the working group of members of the Royal College of Psychiatrists, the Royal College of Physicians and the Royal College of Pathologists. Dr Robinson trains and lectures nationally and internationally on the guidelines, advising on how they should be applied.

The guidelines were the result of close collaboration between psychiatrists, physicians and pathologists in a working group that included Newbridge House psychiatrist Dr Tony Winston.

Dr Robinson emphasised how a bio-psycho-social approach is essential to treat and safely manage people with anorexia. “You have to treat the body and the mind at the same time and for clinicians on a general medical ward there is a particular challenge: they are used to patients who want to get better.

“Patients with anorexia behave as though they don’t want to get better and will have sabotaging behaviours which work against treatment. This can cause havoc in a busy general medical environment.”

Safe management depends upon careful assessment of three areas: physical risk, psychiatric assessment and also, the assessment of capacity (plus consideration of the need for compulsion).

The audience were asked to consider the management of two clinical case studies – how they would be safely managed and decisions to make. There was reflection on the fact that many hospitals are located a long distance from any specialist eating disorders services. Equally, these hospitals may see only one or two acutely ill patients with anorexia each year, so there is inevitably a knowledge gap.

There was audience discussion about how often young people leave inpatient treatment for anorexia and quickly move away from home to university. Participants reflected on the risk this presents and the difficulties in achieving a supported transition, as links to university health services are not easily made.

Dr Robinson introduced the checklist he has developed for general medicine, covering all the assessments which must be carried out immediately on admission of a patient with anorexia. The checklist is due to be published shortly by the Royal College of Psychiatrists, Faculty of Eating Disorders.

He also emphasised the role of the ‘pop-up specialist eating disorders unit’: how general medical services can pool expertise, even if specialists are located a long distance away and phone calls are required when clinicians cannot be there in person. Ideally, hospitals should establish their own MARSIPAN groups, to establish protocols and prepare for admissions.

Professor Hubert Lacey, medical director of Newbridge House commented: “Dr Robinson is a highly respected colleague of many years and we were delighted he was able to deliver this Master Class.

“We fully concur with his view that specialist units like ourselves have a role to play not only with the patients we are treating, but those who may be on our waiting list and beyond – to any services who need advice and support with the patients they are treating.

“We regularly speak to colleagues in general medicine and will always support them as part of the wider responsibility specialist units like ourselves must fulfil.”